"BUSINESS YEAR","STATE CODE","ISSUER ID","SOURCE NAME","VERSION NUMBER","IMPORT DATE","STANDARD COMPONENT ID","PLAN ID","BENEFIT NAME","IS EHB","IS STATE MANDATE","IS COVERED","QUANTITY LIMIT ON SVC","LIMIT QUANTITY","LIMIT UNIT","MINIMUM STAY",EXCLUSIONS,EXPLANATION,"EHB VAR REASON","IS SUBJECTED TO DED TIER 1","IS SUBJECTED TO DED TIER 2","IS EXCLUDED FROM INN MOOP","IS EXCLUDED FROM OON MOOP"
2024,ID,10204,SERFF,1,2/12/2024,10204ID0070002,10204ID0070002-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,10204,SERFF,1,2/12/2024,10204ID0070002,10204ID0070002-01,"Major Dental Care - Adult",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0070002,10204ID0070002-01,"Orthodontia - Child",Yes,,Yes,,,,,,,,,,No,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0070002,10204ID0070002-01,"Major Dental Care - Child",Yes,,Yes,,,,,,,,,,No,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0070002,10204ID0070002-01,"Routine Dental Services (Adult)",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0070002,10204ID0070002-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,,,,,No,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0070002,10204ID0070002-01,"Dental Check-Up for Children",Yes,,Yes,,,,,,,,,,No,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0070002,10204ID0070002-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,10204,SERFF,1,2/12/2024,10204ID0070002,10204ID0070002-01,"Basic Dental Care - Adult",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0080002,10204ID0080002-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,10204,SERFF,1,2/12/2024,10204ID0080002,10204ID0080002-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,10204,SERFF,1,2/12/2024,10204ID0080002,10204ID0080002-01,"Orthodontia - Child",Yes,,Yes,,,,,,,,,,No,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0080002,10204ID0080002-01,"Routine Dental Services (Adult)",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0080002,10204ID0080002-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,,,,,No,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0080002,10204ID0080002-01,"Dental Check-Up for Children",Yes,,Yes,,,,,,,,,,No,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0080002,10204ID0080002-01,"Basic Dental Care - Adult",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0080002,10204ID0080002-01,"Major Dental Care - Child",Yes,,Yes,,,,,,,,,,No,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0080002,10204ID0080002-01,"Major Dental Care - Adult",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0090002,10204ID0090002-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,,,,,No,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0090002,10204ID0090002-01,"Basic Dental Care - Adult",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0090002,10204ID0090002-01,"Major Dental Care - Child",Yes,,Yes,,,,,,,,,,No,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0090002,10204ID0090002-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,10204,SERFF,1,2/12/2024,10204ID0090002,10204ID0090002-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,10204,SERFF,1,2/12/2024,10204ID0090002,10204ID0090002-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,10204,SERFF,1,2/12/2024,10204ID0090002,10204ID0090002-01,"Routine Dental Services (Adult)",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0090002,10204ID0090002-01,"Orthodontia - Child",Yes,,Yes,,,,,,,,,,No,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0090002,10204ID0090002-01,"Dental Check-Up for Children",Yes,,Yes,,,,,,,,,,No,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0100002,10204ID0100002-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,10204,SERFF,1,2/12/2024,10204ID0100002,10204ID0100002-01,"Orthodontia - Child",Yes,,Yes,,,,,,,,,,No,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0100002,10204ID0100002-01,"Major Dental Care - Child",Yes,,Yes,,,,,,,,,,No,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0100002,10204ID0100002-01,"Basic Dental Care - Adult",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0100002,10204ID0100002-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,,,,,No,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0100002,10204ID0100002-01,"Routine Dental Services (Adult)",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0100002,10204ID0100002-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,10204,SERFF,1,2/12/2024,10204ID0100002,10204ID0100002-01,"Dental Check-Up for Children",Yes,,Yes,,,,,,,,,,No,Yes
2024,ID,10204,SERFF,1,2/12/2024,10204ID0100002,10204ID0100002-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020003,17859ID0020003-01,"Major Dental Care - Adult",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020003,17859ID0020003-01,"Major Dental Care - Child",Yes,,Yes,,,,,,,,,,No,No
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020003,17859ID0020003-01,"Routine Dental Services (Adult)",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020003,17859ID0020003-01,"Dental Check-Up for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020003,17859ID0020003-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020003,17859ID0020003-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020003,17859ID0020003-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,,,,,No,No
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020003,17859ID0020003-01,"Orthodontia - Child",Yes,,Yes,,,,,,,,,,No,No
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020003,17859ID0020003-01,"Basic Dental Care - Adult",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020006,17859ID0020006-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020006,17859ID0020006-01,"Major Dental Care - Child",Yes,,Yes,,,,,,,,,,No,No
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020006,17859ID0020006-01,"Routine Dental Services (Adult)",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020006,17859ID0020006-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,,,,,No,No
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020006,17859ID0020006-01,"Major Dental Care - Adult",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020006,17859ID0020006-01,"Orthodontia - Child",Yes,,Yes,,,,,,,,,,No,No
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020006,17859ID0020006-01,"Dental Check-Up for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020006,17859ID0020006-01,"Basic Dental Care - Adult",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020006,17859ID0020006-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020007,17859ID0020007-01,"Routine Dental Services (Adult)",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020007,17859ID0020007-01,"Dental Check-Up for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020007,17859ID0020007-01,"Major Dental Care - Adult",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020007,17859ID0020007-01,"Orthodontia - Child",Yes,,Yes,,,,,,,,,,No,No
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020007,17859ID0020007-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,,,,,No,No
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020007,17859ID0020007-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020007,17859ID0020007-01,"Basic Dental Care - Adult",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020007,17859ID0020007-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020007,17859ID0020007-01,"Major Dental Care - Child",Yes,,Yes,,,,,,,,,,No,No
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020008,17859ID0020008-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020008,17859ID0020008-01,"Orthodontia - Child",Yes,,Yes,,,,,,,,,,No,No
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020008,17859ID0020008-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,,,,,No,No
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020008,17859ID0020008-01,"Routine Dental Services (Adult)",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020008,17859ID0020008-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020008,17859ID0020008-01,"Dental Check-Up for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020008,17859ID0020008-01,"Major Dental Care - Child",Yes,,Yes,,,,,,,,,,No,No
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020008,17859ID0020008-01,"Major Dental Care - Adult",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,17859,SERFF,1,2/12/2024,17859ID0020008,17859ID0020008-01,"Basic Dental Care - Adult",No,,Yes,,,,,,,"Not EHB",,,Yes,Yes
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010005,26002ID0010005-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010007,26002ID0010007-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010009,26002ID0010009-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010011,26002ID0010011-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010012,26002ID0010012-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010018,26002ID0010018-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010028,26002ID0010028-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010029,26002ID0010029-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010033,26002ID0010033-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010036,26002ID0010036-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010037,26002ID0010037-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010039,26002ID0010039-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010040,26002ID0010040-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010045,26002ID0010045-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010046,26002ID0010046-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010047,26002ID0010047-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010048,26002ID0010048-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010049,26002ID0010049-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010050,26002ID0010050-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-04,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-05,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010051,26002ID0010051-06,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010052,26002ID0010052-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010053,26002ID0010053-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010054,26002ID0010054-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010055,26002ID0010055-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010056,26002ID0010056-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010057,26002ID0010057-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010059,26002ID0010059-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-04,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-05,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 5 days. Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 5 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit. Inpatient member responsibility is on a per-day basis, up to 5 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010060,26002ID0010060-06,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Copay per day is after deductible. Member responsibility is on a per-day basis up to 5 days. Covered only in limited circumstances.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Member responsibility is on a per-day basis up to 3 days.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010061,26002ID0010061-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010062,26002ID0010062-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.
","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.
",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010063,26002ID0010063-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances.
",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0010064,26002ID0010064-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030006,26002ID0030006-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030010,26002ID0030010-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030011,26002ID0030011-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030012,26002ID0030012-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030014,26002ID0030014-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030016,26002ID0030016-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030020,26002ID0030020-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030021,26002ID0030021-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030023,26002ID0030023-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030024,26002ID0030024-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030025,26002ID0030025-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days. Inpatient copay applies to inpatient hospital stays related to delivery; please see inpatient benefits for details.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030026,26002ID0030026-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030028,26002ID0030028-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030029,26002ID0030029-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030031,26002ID0030031-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030032,26002ID0030032-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030033,26002ID0030033-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030034,26002ID0030034-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030035,26002ID0030035-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030037,26002ID0030037-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030038,26002ID0030038-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030039,26002ID0030039-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030040,26002ID0030040-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030041,26002ID0030041-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030043,26002ID0030043-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030044,26002ID0030044-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030046,26002ID0030046-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030047,26002ID0030047-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030048,26002ID0030048-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030049,26002ID0030049-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030050,26002ID0030050-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030051,26002ID0030051-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030052,26002ID0030052-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030053,26002ID0030053-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030054,26002ID0030054-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030055,26002ID0030055-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030056,26002ID0030056-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030057,26002ID0030057-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030059,26002ID0030059-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030060,26002ID0030060-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,"Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Member responsibility is on a per-day basis up to 3 days.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030061,26002ID0030061-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030062,26002ID0030062-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030063,26002ID0030063-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030064,26002ID0030064-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030065,26002ID0030065-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030066,26002ID0030066-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030067,26002ID0030067-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Mental/Behavioral Health: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Nutritional Counseling",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Diabetes Education","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,Transplant,Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Accidental Dental",Yes,,Yes,No,,,,"Covered only in limited circumstances","Coinsurance or copay may differ depending on the place where services are received. See inpatient, outpatient, or emergency room benefits.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational therapies have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Generic Drugs",Yes,,Yes,No,,,,,"Certain generic and brand name drugs have lower cost sharing than the generic tier.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Diabetes Education",Yes,,Yes,Yes,5,"Visit(s) per Year",,,"Limits combined with Nutritional Counseling","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Durable Medical Equipment",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,"Certain limitations and exclusions exist. Refer to the plan materials for more information.","Outpatient services for Substance Abuse Disorder: please refer to Outpatient Services for cost sharing information.",,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Reconstructive Surgery",Yes,,Yes,No,,,,"Covered only in limited circumstances",,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Emergency Room Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,"Lenses or contacts, one set per year. Eyeglass frames, one pair per year.
",,"Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Outpatient physical, speech, and occupational therapies have a combined limit of 20 visits. Inpatient physical, speech, and occupational rehabilitation services have no visit limit.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Quantitative limit units apply.","Substantially Equal",,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,26002,SERFF,1,2/12/2024,26002ID0030068,26002ID0030068-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100002,38128ID0100002-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100003,38128ID0100003-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100004,38128ID0100004-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100007,38128ID0100007-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100009,38128ID0100009-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100011,38128ID0100011-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0100012,38128ID0100012-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Generic Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130002,38128ID0130002-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Generic Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130003,38128ID0130003-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Generic Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130006,38128ID0130006-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Generic Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130007,38128ID0130007-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Generic Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130008,38128ID0130008-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Generic Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130009,38128ID0130009-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Generic Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130010,38128ID0130010-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Generic Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0130011,38128ID0130011-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-02,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140001,38128ID0140001-03,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-02,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-03,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-04,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-05,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140002,38128ID0140002-06,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140003,38128ID0140003-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140004,38128ID0140004-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140005,38128ID0140005-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0140006,38128ID0140006-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Generic Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150001,38128ID0150001-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Generic Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150002,38128ID0150002-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Generic Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150004,38128ID0150004-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Generic Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150005,38128ID0150005-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Generic Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150006,38128ID0150006-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Generic Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150007,38128ID0150007-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Generic Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0150008,38128ID0150008-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Some medications may be covered 100%. See formulary for tier 5 $0 list.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160001,38128ID0160001-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160002,38128ID0160002-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160003,38128ID0160003-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160004,38128ID0160004-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Home Health Care Services",Yes,,Yes,Yes,180,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Prosthetic Devices",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Gender Affirming Care",No,,Yes,,,,,,,"Additional EHB Benefit",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Generic Drugs",Yes,,Yes,,,,,,"See formulary at mountainhealth.coop for a list of $0 medications.","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined PT/OT/ST","Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Infusion Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,38128,SERFF,1,2/12/2024,38128ID0160005,38128ID0160005-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290012,44648ID1290012-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-01,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-02,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-03,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-04,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-05,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290015,44648ID1290015-06,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-01,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-02,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290017,44648ID1290017-03,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible. See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information. Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible. See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible. See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information. Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Specialist Visit",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible. See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information. Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible. See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information. Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible. See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible. See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information. Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Specialist Visit",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible. See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information. Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible. See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information. Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible. See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible. See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information. Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Specialist Visit",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible. See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information. Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290018,44648ID1290018-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-01,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-02,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290021,44648ID1290021-03,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1290025,44648ID1290025-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. Se policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. Se policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. Se policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310007,44648ID1310007-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. Se policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. Se policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. Se policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. Se policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. Se policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. Se policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310008,44648ID1310008-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. Se policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. Se policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. Se policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. Se policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. Se policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. Se policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310009,44648ID1310009-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. Se policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-01,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. Se policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-02,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. Se policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1310011,44648ID1310011-03,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350001,44648ID1350001-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-01,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-02,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Specialist Visit",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,Transplant,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT). See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses). See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. See policy for more information.  Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350002,44648ID1350002-03,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information. Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information. Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Specialist Visit",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible.  See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,Transplant,Yes,,Yes,,,,,"Excludes: a) Transplants of brain tissue or brain membrane, islet tissue, pancreas, intestine, pituitary and adrenal glands, hair Transplants, or any other Transplant not specifically named as a Covered Service in this section; or for Artificial Organs including but not limited to, artificial hearts or pancreases. b) Any eligible expenses of a donor related to donating or transplanting an organ or tissue unless the recipient is an Insured who is eligible to receive benefits for Transplant services after benefits for the recipient have been paid, subject to the provisions of this Policy. c) The cost of a human organ or tissue that is sold rather than donated to the recipient. d) Transportation costs including but not limited to, Ambulance Transportation Service or air service for the donor, or to transport a donated organ or tissue. e) Living expenses for the recipient, donor, or family members, except as specifically listed as a Covered Service in this Policy. f) Costs covered or funded by governmental, foundation or charitable grants or programs; or Physician fees or other charges, if no charge is generally made in the absence of insurance coverage. g) Any complication to the donor arising from a donor’s Transplant Surgery is not a covered benefit under the Insured Transplant recipient’s Policy. If the donor is a BCI Insured, eligible to receive benefits for Covered Services, benefits for medical complications to the donor arising from Transplant Surgery will be allowed under the donor’s policy. h) Costs related to the search for a suitable donor.","See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible.  See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible.  See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible.  See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information. Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information. Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information. Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Specialist Visit",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible.  See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,Transplant,Yes,,Yes,,,,,"Excludes: a) Transplants of brain tissue or brain membrane, islet tissue, pancreas, intestine, pituitary and adrenal glands, hair Transplants, or any other Transplant not specifically named as a Covered Service in this section; or for Artificial Organs including but not limited to, artificial hearts or pancreases. b) Any eligible expenses of a donor related to donating or transplanting an organ or tissue unless the recipient is an Insured who is eligible to receive benefits for Transplant services after benefits for the recipient have been paid, subject to the provisions of this Policy. c) The cost of a human organ or tissue that is sold rather than donated to the recipient. d) Transportation costs including but not limited to, Ambulance Transportation Service or air service for the donor, or to transport a donated organ or tissue. e) Living expenses for the recipient, donor, or family members, except as specifically listed as a Covered Service in this Policy. f) Costs covered or funded by governmental, foundation or charitable grants or programs; or Physician fees or other charges, if no charge is generally made in the absence of insurance coverage. g) Any complication to the donor arising from a donor’s Transplant Surgery is not a covered benefit under the Insured Transplant recipient’s Policy. If the donor is a BCI Insured, eligible to receive benefits for Covered Services, benefits for medical complications to the donor arising from Transplant Surgery will be allowed under the donor’s policy. h) Costs related to the search for a suitable donor.","See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible.  See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible.  See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible.  See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information. Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,"See policy for information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information. Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Diabetes Education",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Basic Dental Care - Child",Yes,,Yes,Yes,2,"Exam(s) per Year",,,"See policy for more information.","Additional EHB Benefit",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information. Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Infusion Therapy",Yes,,Yes,,,,,,"Services, Supplies and Drugs including Home Infusion Therapy (Parenteral/Enteral in the home), Infusion Pump. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Hearing Aids",No,,Yes,,,,,,"Hearing loss coverage complies with state law.  See policy for more information","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Specialist Visit",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible.  See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,Dialysis,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Covered for all conditions, including diabetic counseling. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,Radiation,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Routine Foot Care",No,,Yes,,,,,,"Covered when medically necessary. See policy for more information.","Not EHB",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Allergy Testing",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Home Health Care Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Accidental Dental",Yes,,Yes,,,,,,"Services to treat injury of the natural teeth.  Services must be provided within 12 months of the injury. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Major Dental Care - Child",Yes,,Yes,,,,,,"Quantitative limits apply. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Reconstructive Surgery",Yes,,Yes,,,,,,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Extremity Prosthetics. See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,Transplant,Yes,,Yes,,,,,"Excludes: a) Transplants of brain tissue or brain membrane, islet tissue, pancreas, intestine, pituitary and adrenal glands, hair Transplants, or any other Transplant not specifically named as a Covered Service in this section; or for Artificial Organs including but not limited to, artificial hearts or pancreases. b) Any eligible expenses of a donor related to donating or transplanting an organ or tissue unless the recipient is an Insured who is eligible to receive benefits for Transplant services after benefits for the recipient have been paid, subject to the provisions of this Policy. c) The cost of a human organ or tissue that is sold rather than donated to the recipient. d) Transportation costs including but not limited to, Ambulance Transportation Service or air service for the donor, or to transport a donated organ or tissue. e) Living expenses for the recipient, donor, or family members, except as specifically listed as a Covered Service in this Policy. f) Costs covered or funded by governmental, foundation or charitable grants or programs; or Physician fees or other charges, if no charge is generally made in the absence of insurance coverage. g) Any complication to the donor arising from a donor’s Transplant Surgery is not a covered benefit under the Insured Transplant recipient’s Policy. If the donor is a BCI Insured, eligible to receive benefits for Covered Services, benefits for medical complications to the donor arising from Transplant Surgery will be allowed under the donor’s policy. h) Costs related to the search for a suitable donor.","See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"One pair of lenses and one frame per year (contacts in lieu of glasses).  See policy for more information","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible.  See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible.  See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Gender Affirming Care",No,,Yes,,,,,,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services.","Other Law/Regulation",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Generic Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Emergency Room Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,"See policy for information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"See policy for more information.","Substantially Equal",,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Orthodontia - Child",Yes,,Yes,,,,,,"Medically necessary orthodontia. See policy for more information.",,,,No,Yes
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,Chemotherapy,Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Specialty Drugs",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Hospice Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,"The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible.  See policy for more information.","Substantially Equal",,,No,No
2024,ID,44648,SERFF,1,2/12/2024,44648ID1350003,44648ID1350003-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes.  See policy for more information. Visit limit does not apply to Mental Health/Substance Abuse.",,,,No,No
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020005,46641ID0020005-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link","Substantially Equal",,,No,No
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020005,46641ID0020005-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020005,46641ID0020005-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020005,46641ID0020005-01,"Orthodontia - Child",Yes,,Yes,,,,,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Covered only if medically necessary as per the Idaho Smiles Malocclusion Index. Must meet 8 out of 12 points to qualify.","Substantially Equal",,,No,No
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020005,46641ID0020005-01,"Basic Dental Care - Adult",No,,Yes,,,,,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","The adult deductible is $50.  The adult year to date maximum is $1,500. The waiting period for Basic Services is 6 months.  Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Not EHB",,,Yes,Yes
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020005,46641ID0020005-01,"Major Dental Care - Child",Yes,,Yes,,,,,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Substantially Equal",,,No,No
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020005,46641ID0020005-01,"Major Dental Care - Adult",No,,Yes,,,,,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","The adult deductible is $50.  The adult year to date maximum is $1,500. The waiting period for Major Services is 12 months.  Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Not EHB",,,Yes,Yes
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020005,46641ID0020005-01,"Routine Dental Services (Adult)",No,,Yes,Yes,2,"Visit(s) per Year",,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","The adult year to date maximum is $1,500 per year.  Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Not EHB",,,Yes,Yes
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020005,46641ID0020005-01,"Basic Dental Care - Child",Yes,,Yes,,,,,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Substantially Equal",,,No,No
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020006,46641ID0020006-01,"Major Dental Care - Adult",No,,Yes,,,,,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","The adult deductible is $50. The adult year to date maximum is $1,500. The waiting period for Major Services is 12 months. Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Not EHB",,,Yes,Yes
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020006,46641ID0020006-01,"Routine Dental Services (Adult)",No,,Yes,Yes,2,"Visit(s) per Year",,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","The adult year to date maximum is $1,500. Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Not EHB",,,Yes,Yes
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020006,46641ID0020006-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020006,46641ID0020006-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Substantially Equal",,,No,No
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020006,46641ID0020006-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020006,46641ID0020006-01,"Basic Dental Care - Adult",No,,Yes,,,,,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","The adult deductible is $50. The adult year to date maximum is $1,500. The waiting period for Basic Services is 6 months. Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Not EHB",,,Yes,Yes
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020006,46641ID0020006-01,"Major Dental Care - Child",Yes,,Yes,,,,,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Substantially Equal",,,No,No
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020006,46641ID0020006-01,"Orthodontia - Child",Yes,,Yes,,,,,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Covered only if medically necessary as per the Idaho Smiles Malocclusion Index. Must meet 8 out of 12 points to qualify.","Substantially Equal",,,No,No
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020006,46641ID0020006-01,"Basic Dental Care - Child",Yes,,Yes,,,,,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Substantially Equal",,,No,No
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020007,46641ID0020007-01,"Basic Dental Care - Adult",No,,Yes,,,,,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","The adult deductible is $75. 
The adult annual maximum is $1,000.
The waiting period for Basic Services is 6 months.
Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Not EHB",,,Yes,Yes
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020007,46641ID0020007-01,"Routine Dental Services (Adult)",No,,Yes,Yes,2,"Visit(s) per Year",,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","The adult year to date maximum is $1,000.
Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Not EHB",,,Yes,Yes
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020007,46641ID0020007-01,"Major Dental Care - Child",Yes,,Yes,,,,,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Using Alternate Benchmark",,,No,No
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020007,46641ID0020007-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Substantially Equal",,,No,No
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020007,46641ID0020007-01,"Basic Dental Care - Child",Yes,,Yes,,,,,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Substantially Equal",,,No,No
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020007,46641ID0020007-01,"Orthodontia - Child",Yes,,Yes,,,,,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Covered only if medically necessary as per the Idaho Smiles Malocclusion Index. Must meet 8 out of 12 points to qualify.","Substantially Equal",,,No,No
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020007,46641ID0020007-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020007,46641ID0020007-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020007,46641ID0020007-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020008,46641ID0020008-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020008,46641ID0020008-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020008,46641ID0020008-01,"Basic Dental Care - Child",Yes,,Yes,,,,,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Substantially Equal",,,No,No
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020008,46641ID0020008-01,"Orthodontia - Child",Yes,,Yes,,,,,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Covered only if medically necessary as per the Idaho Smiles Malocclusion Index. Must meet 8 out of 12 points to qualify.","Substantially Equal",,,No,No
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020008,46641ID0020008-01,"Major Dental Care - Child",Yes,,Yes,,,,,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Substantially Equal",,,No,No
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020008,46641ID0020008-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Substantially Equal",,,No,No
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020008,46641ID0020008-01,"Basic Dental Care - Adult",No,,Yes,,,,,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","The adult deductible is $75. 
The adult annual maximum is $1,000.
The waiting period for Basic Services is 6 months.
Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Not EHB",,,Yes,Yes
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020008,46641ID0020008-01,"Routine Dental Services (Adult)",No,,Yes,Yes,2,"Visit(s) per Year",,"Exclusions are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","The adult year to date maximum is $1,000.
Benefit details are listed in the Outline of Coverages which is attached under the Summary of Benefits link.","Not EHB",,,Yes,Yes
2024,ID,46641,SERFF,1,2/12/2024,46641ID0020008,46641ID0020008-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010001,48872ID0010001-01,"Basic Dental Care - Adult",No,,Yes,No,,,,"Space Maintainers not covered after the end of the month the enrollee turns age 19.  Fillings on the same surface 1 every 18 months.  Basic benefits covered after 6 month waiting period.","Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Not EHB",,,Yes,Yes
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010001,48872ID0010001-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Limit applies to Exams, Cleanings and Fluoride.  Vertical Bitewing X-rays up to 8 films every 6 months.  Panoramic X-Ray is allowed 1 every 3 years.  Fluoride and Sealants not covered after the end of the month the enrollee turns age 19.  Sealants are covered 1 per tooth every 36 months.  Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Substantially Equal",,,No,No
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010001,48872ID0010001-01,"Routine Dental Services (Adult)",No,,Yes,Yes,2,"Visit(s) per Year",,,"Limit applies to Exams, Cleanings and Fluoride.  Vertical Bitewing X-rays up to 8 films every 6 months.  Panoramic X-Ray is allowed 1 every 3 years.  Fluoride and Sealants not covered after the end of the month the enrollee turns age 19.  Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Not EHB",,,Yes,Yes
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010001,48872ID0010001-01,"Orthodontia - Child",Yes,,Yes,No,,,,"Covered up to the end of the month the enrollee turns age 19.","Non-Medically Necessary and Medically Necessary Ortho are covered.  Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Substantially Equal",,,No,No
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010001,48872ID0010001-01,"Major Dental Care - Adult",No,,Yes,No,,,,"Anesthesia only covered when medically or dentally necessary.  Implants are not covered.  Crowns, Pontics, Abutments, Onlays and Dentures are covered 1 every 5 years per tooth.  Waiting period applies.","Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Not EHB",,,Yes,Yes
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010001,48872ID0010001-01,"Major Dental Care - Child",Yes,,Yes,No,,,,"Anesthesia is only covered when medically or dentally necessary.  Implants not covered after the end of the month the enrollee turns age 19.  Crowns, Pontics, Abutments, Onlays and Dentures are covered 1 every 5 years per tooth.","Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Substantially Equal",,,No,No
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010001,48872ID0010001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010001,48872ID0010001-01,"Basic Dental Care - Child",Yes,,Yes,No,,,,"Space Maintainers not covered after the end of the month the enrollee turns age 19.","Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Substantially Equal",,,No,No
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010001,48872ID0010001-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010002,48872ID0010002-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Limit applies to Exams, Cleanings and Fluoride.  Vertical Bitewing X-rays up to 8 films every 6 months.  Panoramic X-Ray is allowed 1 every 3 years.  Fluoride and Sealants not covered after the end of the month the enrollee turns age 19.  Sealants are covered 1 per tooth every 36 months.  Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Substantially Equal",,,No,No
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010002,48872ID0010002-01,"Routine Dental Services (Adult)",No,,Yes,Yes,2,"Visit(s) per Year",,,"Limit applies to Exams, Cleanings and Fluoride.  Vertical Bitewing X-rays up to 8 films every 6 months.  Panoramic X-Ray is allowed 1 every 3 years.  Fluoride and Sealants not covered after the end of the month the enrollee turns age 19.  Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Not EHB",,,Yes,Yes
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010002,48872ID0010002-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010002,48872ID0010002-01,"Basic Dental Care - Child",Yes,,Yes,No,,,,"Space Maintainers not covered after the end of the month the enrollee turns age 19.","Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Substantially Equal",,,No,No
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010002,48872ID0010002-01,"Major Dental Care - Adult",No,,Yes,No,,,,"Anesthesia only covered when medically or dentally necessary.  Implants are not covered.  Crowns, Pontics, Abutments, Onlays and Dentures are covered 1 every 5 years per tooth.  Waiting period applies.","Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Not EHB",,,Yes,Yes
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010002,48872ID0010002-01,"Major Dental Care - Child",Yes,,Yes,No,,,,"Anesthesia is only covered when medically or dentally necessary.  Implants not covered after the end of the month the enrollee turns age 19.  Crowns, Pontics, Abutments, Onlays and Dentures are covered 1 every 5 years per tooth.","Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Substantially Equal",,,No,No
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010002,48872ID0010002-01,"Basic Dental Care - Adult",No,,Yes,No,,,,"Space Maintainers not covered after the end of the month the enrollee turns age 19.  Fillings on the same surface 1 every 18 months.  Basic benefits covered after 6 month waiting period.","Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Not EHB",,,Yes,Yes
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010002,48872ID0010002-01,"Orthodontia - Child",Yes,,Yes,No,,,,"Covered up to the end of the month the enrollee turns age 19.","Only Medically Necessary Ortho is covered.  Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Substantially Equal",,,No,No
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010002,48872ID0010002-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010003,48872ID0010003-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010003,48872ID0010003-01,"Major Dental Care - Child",Yes,,Yes,No,,,,"Anesthesia is only covered when medically or dentally necessary.  Implants not covered after the end of the month the enrollee turns age 19.  Crowns, Pontics, Abutments, Onlays and Dentures are covered 1 every 5 years per tooth.","Copays listed are average copays for this benefit category.  For detailed copays by service please reference the copay schedule linked to the Advantage Copay plan brochure.  Benefits illustrated are in summary only.  Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.","Substantially Equal",,,No,No
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010003,48872ID0010003-01,"Orthodontia - Child",Yes,,Yes,No,,,,"Covered up to the end of the month the enrollee turns age 19.","Only Medically Necessary Ortho is covered.  Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Substantially Equal",,,No,No
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010003,48872ID0010003-01,"Basic Dental Care - Child",Yes,,Yes,No,,,,"Space Maintainers not covered after the end of the month the enrollee turns age 19.","Copays listed are average copays for this benefit category.  For detailed copays by service please reference the copay schedule linked to the Advantage Copay plan brochure.  Benefits illustrated are in summary only.  Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.","Substantially Equal",,,No,No
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010003,48872ID0010003-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Limit applies to Exams, Cleanings and Fluoride.  Vertical Bitewing X-rays up to 8 films every 6 months.  Panoramic X-Ray is allowed 1 every 3 years.  Fluoride and Sealants not covered after the end of the month the enrollee turns age 19.   Sealants are covered 1 per tooth every 36 months.  Copays listed are average copays for this benefit category.  For detailed copays by service please reference the copay schedule linked to the Advantage Copay plan brochure.  Benefits illustrated are in summary only.  Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.","Substantially Equal",,,No,No
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010003,48872ID0010003-01,"Routine Dental Services (Adult)",No,,Yes,Yes,2,"Visit(s) per Year",,,"Limit applies to Exams, Cleanings and Fluoride.  Vertical Bitewing X-rays up to 8 films every 6 months.  Panoramic X-Ray is allowed 1 every 3 years.  Fluoride and Sealants not covered after the end of the month the enrollee turns age 19.  Copays listed are average copays for this benefit category.  For detailed copays by service please reference the copay schedule linked to the Advantage Copay plan brochure.  Benefits illustrated are in summary only.  Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.","Not EHB",,,Yes,Yes
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010003,48872ID0010003-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010003,48872ID0010003-01,"Major Dental Care - Adult",No,,Yes,No,,,,"Anesthesia only covered when medically or dentally necessary.  Implants are not covered.  Crowns, Pontics, Abutments, Onlays and Dentures are covered 1 every 5 years per tooth.  Waiting period applies.","Copays listed are average copays for this benefit category.  For detailed copays by service please reference the copay schedule linked to the Advantage Copay plan brochure.  Benefits illustrated are in summary only.  Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.","Not EHB",,,Yes,Yes
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010003,48872ID0010003-01,"Basic Dental Care - Adult",No,,Yes,No,,,,"Space Maintainers not covered after the end of the month the enrollee turns age 19.  Fillings on the same surface 1 every 18 months.  Basic benefits covered after 6 month waiting period.","Copays listed are average copays for this benefit category.  For detailed copays by service please reference the copay schedule linked to the Advantage Copay plan brochure.  Benefits illustrated are in summary only.  Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.","Not EHB",,,Yes,Yes
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010004,48872ID0010004-01,"Major Dental Care - Child",Yes,,Yes,No,,,,"Anesthesia is only covered when medically or dentally necessary.  Implants not covered after the end of the month the enrollee turns age 19.  Crowns, Pontics, Abutments, Onlays and Dentures are covered 1 every 5 years per tooth.","Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Substantially Equal",,,No,No
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010004,48872ID0010004-01,"Basic Dental Care - Child",Yes,,Yes,No,,,,"Space Maintainers not covered after the end of the month the enrollee turns age 19.","Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Substantially Equal",,,No,No
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010004,48872ID0010004-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Limit applies to Exams, Cleanings and Fluoride.  Vertical Bitewing X-rays up to 8 films every 6 months.  Panoramic X-Ray is allowed 1 every 3 years.  Fluoride and Sealants not covered after the end of the month the enrollee turns age 19.  Sealants are covered 1 per tooth every 36 months.  Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Substantially Equal",,,No,No
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010004,48872ID0010004-01,"Orthodontia - Child",Yes,,Yes,No,,,,"Covered up to the end of the month the enrollee turns age 19.","Only Medically Necessary Ortho is covered.  Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Substantially Equal",,,No,No
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010004,48872ID0010004-01,"Basic Dental Care - Adult",No,,Yes,No,,,,"Space Maintainers not covered after the end of the month the enrollee turns age 19.  Fillings on the same surface 1 every 18 months.  Basic benefits covered after 6 month waiting period.","Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Not EHB",,,Yes,Yes
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010004,48872ID0010004-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010004,48872ID0010004-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010004,48872ID0010004-01,"Routine Dental Services (Adult)",No,,Yes,Yes,2,"Visit(s) per Year",,,"Limit applies to Exams, Cleanings and Fluoride.  Vertical Bitewing X-rays up to 8 films every 6 months.  Panoramic X-Ray is allowed 1 every 3 years.  Fluoride and Sealants not covered after the end of the month the enrollee turns age 19.  Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Not EHB",,,Yes,Yes
2024,ID,48872,SERFF,1,2/12/2024,48872ID0010004,48872ID0010004-01,"Major Dental Care - Adult",No,,Yes,No,,,,"Anesthesia only covered when medically or dentally necessary.  Implants are not covered.  Crowns, Pontics, Abutments, Onlays and Dentures are covered 1 every 5 years per tooth.  Waiting period applies.","Benefits illustrated are in summary only.  Refer to the plan brochure for additional details.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-02,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-03,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-04,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-05,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350001,60597ID0350001-06,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350004,60597ID0350004-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350005,60597ID0350005-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350007,60597ID0350007-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350008,60597ID0350008-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350009,60597ID0350009-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0350010,60597ID0350010-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-02,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360002,60597ID0360002-03,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360003,60597ID0360003-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-01,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-02,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-03,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-04,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-05,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360008,60597ID0360008-06,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360009,60597ID0360009-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360010,60597ID0360010-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360011,60597ID0360011-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Cosmetic Surgery",No,,No,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,"Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,"Reimbursement for benefits for air ambulance is limited to 200% of the current Medicare allowable amount. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out of network providers are paid at the in network provider level. Out of network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,"Orthoptics, vision therapy, or other services to correct refractive error. ","Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. Out of network: No charge up to $40 maximum.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,"Confinement or custodial care is not covered. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0360012,60597ID0360012-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380001,60597ID0380001-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380002,60597ID0380002-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380003,60597ID0380003-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380004,60597ID0380004-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380005,60597ID0380005-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380006,60597ID0380006-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380007,60597ID0380007-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380008,60597ID0380008-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0380010,60597ID0380010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400001,60597ID0400001-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400002,60597ID0400002-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400003,60597ID0400003-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400005,60597ID0400005-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400006,60597ID0400006-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400007,60597ID0400007-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400008,60597ID0400008-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400009,60597ID0400009-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0400010,60597ID0400010-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410001,60597ID0410001-01,"Orthodontia - Child",Yes,,Yes,,,,,"Coverage for orthodontia services are excluded unless medically necessary.","Medically necessary orthodontia requires a predetermination and a treatment plan.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410001,60597ID0410001-01,"Major Dental Care - Adult",No,,Yes,,,,,"Separate charges for denture adjustments and relines performed within 6 months of initial placement.","Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Charge for root canal therapy 1 per tooth per 36 months. Crowns and other restorations 1 per tooth per 10 years. Replacement of existing prosthetic only when unserviceable and in place at least 10 years. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months. Initial placement only covered if natural tooth lost or extracted while coverage is in effect or after at least 36 consecutive months. Surgical placement and removal of implants 1 per tooth space per lifetime. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410001,60597ID0410001-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410001,60597ID0410001-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months.  Surgical placement and removal of implants 1 per tooth space per 60 months.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410001,60597ID0410001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410001,60597ID0410001-01,"Routine Dental Services (Adult)",No,,Yes,,,,,"Space maintainers, athletic mouth guards, and sealants are not covered for members age 19 and older.","Periodic exams 2 per year. Comprehensive exams 2 per year. Full mouth, cone beams, or panorex x-rays 1 set per 60 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Brush biopsies to aid in diagnosis of oral cancer are covered. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410001,60597ID0410001-01,"Accidental Dental",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410001,60597ID0410001-01,"Basic Dental Care - Adult",No,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 36 months. Full mouth debridement 1 every 36 month only if no prophylaxis in the prior 36 months and an exam cannot be performed due to obstruction. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410001,60597ID0410001-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 60 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year.  Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410002,60597ID0410002-01,"Accidental Dental",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410002,60597ID0410002-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410002,60597ID0410002-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410002,60597ID0410002-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410002,60597ID0410002-01,"Orthodontia - Child",Yes,,Yes,,,,,"Coverage for orthodontia services are excluded unless medically necessary. ","Medically necessary orthodontia requires a predetermination and a treatment plan.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410002,60597ID0410002-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 60 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year.  Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410002,60597ID0410002-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410002,60597ID0410002-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410002,60597ID0410002-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months.  Surgical placement and removal of implants 1 per tooth space per 60 months.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410003,60597ID0410003-01,"Basic Dental Care - Adult",No,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 36 months. Full mouth debridement 1 every 36 month only if no prophylaxis in the prior 36 months and an exam cannot be performed due to obstruction. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410003,60597ID0410003-01,"Routine Dental Services (Adult)",No,,Yes,,,,,"Space maintainers, athletic mouth guards, and sealants are not covered for members age 19 and older.","Periodic exams 2 per year. Comprehensive exams 2 per year. Full mouth, cone beams, or panorex x-rays 1 set per 60 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Brush biopsies to aid in diagnosis of oral cancer are covered. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410003,60597ID0410003-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410003,60597ID0410003-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months.  Surgical placement and removal of implants 1 per tooth space per 60 months.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410003,60597ID0410003-01,"Orthodontia - Child",Yes,,Yes,,,,,"Coverage for orthodontia services are excluded unless medically necessary.","Medically necessary orthodontia requires a predetermination and a treatment plan.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410003,60597ID0410003-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 60 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year.  Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410003,60597ID0410003-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410003,60597ID0410003-01,"Major Dental Care - Adult",No,,Yes,,,,,"Separate charges for denture adjustments and relines performed within 6 months of initial placement.","Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Charge for root canal therapy 1 per tooth per 36 months. Crowns and other restorations 1 per tooth per 10 years. Replacement of existing prosthetic only when unserviceable and in place at least 10 years. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months. Initial placement only covered if natural tooth lost or extracted while coverage is in effect or after at least 36 consecutive months. Surgical placement and removal of implants 1 per tooth space per lifetime. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0410003,60597ID0410003-01,"Accidental Dental",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420001,60597ID0420001-01,"Accidental Dental",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420001,60597ID0420001-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420001,60597ID0420001-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420001,60597ID0420001-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420001,60597ID0420001-01,"Basic Dental Care - Adult",No,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 36 month only if no prophylaxis in the prior 36 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Charge for root canal therapy 1 per tooth per 36 months. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420001,60597ID0420001-01,"Orthodontia - Child",Yes,,Yes,,,,,"Coverage for orthodontia services are excluded unless medically necessary.","Medically necessary orthodontia requires a predetermination and a treatment plan.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420001,60597ID0420001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420001,60597ID0420001-01,"Routine Dental Services (Adult)",No,,Yes,,,,,"Space maintainers, athletic mouth guards, and sealants are not covered for members age 19 and older.","Periodic exams 2 per year. Comprehensive exams 2 per year. Full mouth, cone beams, or panorex x-rays 1 set per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 3 per year. Fluoride applications 4 per year. Brush biopsies to aid in diagnosis of oral cancer are covered. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420001,60597ID0420001-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months.  Surgical placement and removal of implants 1 per tooth space per 60 months.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420002,60597ID0420002-01,"Orthodontia - Child",Yes,,Yes,,,,,"Coverage for orthodontia services are excluded unless medically necessary.","Medically necessary orthodontia requires a predetermination and a treatment plan.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420002,60597ID0420002-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months.  Surgical placement and removal of implants 1 per tooth space per 60 months.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420002,60597ID0420002-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420002,60597ID0420002-01,"Basic Dental Care - Adult",No,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 36 month only if no prophylaxis in the prior 36 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Charge for root canal therapy 1 per tooth per 36 months. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420002,60597ID0420002-01,"Routine Dental Services (Adult)",No,,Yes,,,,,"Space maintainers, athletic mouth guards, and sealants are not covered for members age 19 and older.","Periodic exams 2 per year. Comprehensive exams 2 per year. Full mouth, cone beams, or panorex x-rays 1 set per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 3 per year. Fluoride applications 4 per year. Brush biopsies to aid in diagnosis of oral cancer are covered. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420002,60597ID0420002-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420002,60597ID0420002-01,"Accidental Dental",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420002,60597ID0420002-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420002,60597ID0420002-01,"Major Dental Care - Adult",No,,Yes,,,,,"Separate charges for denture adjustments and relines performed within 6 months of initial placement.","Crowns and other restorations 1 per tooth per 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months. Initial placement only covered if natural tooth lost or extracted while coverage is in effect or after at least 36 consecutive months. Surgical placement and removal of implants 1 per tooth space per lifetime. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420003,60597ID0420003-01,"Accidental Dental",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420003,60597ID0420003-01,"Orthodontia - Child",Yes,,Yes,,,,,"Coverage for orthodontia services are excluded unless medically necessary.","Medically necessary orthodontia requires a predetermination and a treatment plan.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420003,60597ID0420003-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420003,60597ID0420003-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420003,60597ID0420003-01,"Routine Dental Services (Adult)",No,,Yes,,,,,"Space maintainers, athletic mouth guards, and sealants are not covered for members age 19 and older.","Periodic exams 2 per year. Comprehensive exams 2 per year. Full mouth, cone beams, or panorex x-rays 1 set per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 3 per year. Fluoride applications 4 per year. Brush biopsies to aid in diagnosis of oral cancer are covered. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420003,60597ID0420003-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months.  Surgical placement and removal of implants 1 per tooth space per 60 months.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420003,60597ID0420003-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420003,60597ID0420003-01,"Basic Dental Care - Adult",No,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 36 month only if no prophylaxis in the prior 36 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Charge for root canal therapy 1 per tooth per 36 months. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420003,60597ID0420003-01,"Major Dental Care - Adult",No,,Yes,,,,,"Separate charges for denture adjustments and relines performed within 6 months of initial placement.","Crowns and other restorations 1 per tooth per 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months. Initial placement only covered if natural tooth lost or extracted while coverage is in effect or after at least 36 consecutive months. Surgical placement and removal of implants 1 per tooth space per lifetime. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420004,60597ID0420004-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420004,60597ID0420004-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months.  Surgical placement and removal of implants 1 per tooth space per 60 months.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420004,60597ID0420004-01,"Orthodontia - Child",Yes,,Yes,,,,,"Coverage for orthodontia services are excluded unless medically necessary.","Medically necessary orthodontia requires a predetermination and a treatment plan.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420004,60597ID0420004-01,"Basic Dental Care - Adult",No,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 36 month only if no prophylaxis in the prior 36 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Charge for root canal therapy 1 per tooth per 36 months. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420004,60597ID0420004-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420004,60597ID0420004-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420004,60597ID0420004-01,"Accidental Dental",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420004,60597ID0420004-01,"Major Dental Care - Adult",No,,Yes,,,,,"Separate charges for denture adjustments and relines performed within 6 months of initial placement.","Crowns and other restorations 1 per tooth per 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months. Initial placement only covered if natural tooth lost or extracted while coverage is in effect or after at least 36 consecutive months. Surgical placement and removal of implants 1 per tooth space per lifetime. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420004,60597ID0420004-01,"Routine Dental Services (Adult)",No,,Yes,,,,,"Space maintainers, athletic mouth guards, and sealants are not covered for members age 19 and older.","Periodic exams 2 per year. Comprehensive exams 2 per year. Full mouth, cone beams, or panorex x-rays 1 set per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 3 per year. Fluoride applications 4 per year. Brush biopsies to aid in diagnosis of oral cancer are covered. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420005,60597ID0420005-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420005,60597ID0420005-01,"Major Dental Care - Adult",No,,Yes,,,,,"Separate charges for denture adjustments and relines performed within 6 months of initial placement.","Crowns and other restorations 1 per tooth per 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months. Initial placement only covered if natural tooth lost or extracted while coverage is in effect or after at least 36 consecutive months. Surgical placement and removal of implants 1 per tooth space per lifetime. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420005,60597ID0420005-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420005,60597ID0420005-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420005,60597ID0420005-01,"Accidental Dental",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420005,60597ID0420005-01,"Basic Dental Care - Adult",No,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 36 month only if no prophylaxis in the prior 36 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Charge for root canal therapy 1 per tooth per 36 months. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420005,60597ID0420005-01,"Orthodontia - Child",Yes,,Yes,,,,,"Coverage for orthodontia services are excluded unless medically necessary.","Medically necessary orthodontia requires a predetermination and a treatment plan.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420005,60597ID0420005-01,"Routine Dental Services (Adult)",No,,Yes,,,,,"Space maintainers, athletic mouth guards, and sealants are not covered for members age 19 and older.","Periodic exams 2 per year. Comprehensive exams 2 per year. Full mouth, cone beams, or panorex x-rays 1 set per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 3 per year. Fluoride applications 4 per year. Brush biopsies to aid in diagnosis of oral cancer are covered. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420005,60597ID0420005-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months.  Surgical placement and removal of implants 1 per tooth space per 60 months.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420006,60597ID0420006-01,"Accidental Dental",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420006,60597ID0420006-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months.  Surgical placement and removal of implants 1 per tooth space per 60 months.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420006,60597ID0420006-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420006,60597ID0420006-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420006,60597ID0420006-01,"Basic Dental Care - Adult",No,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 36 month only if no prophylaxis in the prior 36 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Charge for root canal therapy 1 per tooth per 36 months. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420006,60597ID0420006-01,"Orthodontia - Child",Yes,,Yes,,,,,"Coverage for orthodontia services are excluded unless medically necessary.","Medically necessary orthodontia requires a predetermination and a treatment plan.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420006,60597ID0420006-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420006,60597ID0420006-01,"Major Dental Care - Adult",No,,Yes,,,,,"Separate charges for denture adjustments and relines performed within 6 months of initial placement.","Crowns and other restorations 1 per tooth per 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months. Initial placement only covered if natural tooth lost or extracted while coverage is in effect or after at least 36 consecutive months. Surgical placement and removal of implants 1 per tooth space per lifetime. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420006,60597ID0420006-01,"Routine Dental Services (Adult)",No,,Yes,,,,,"Space maintainers, athletic mouth guards, and sealants are not covered for members age 19 and older.","Periodic exams 2 per year. Comprehensive exams 2 per year. Full mouth, cone beams, or panorex x-rays 1 set per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 3 per year. Fluoride applications 4 per year. Brush biopsies to aid in diagnosis of oral cancer are covered. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420007,60597ID0420007-01,"Accidental Dental",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420007,60597ID0420007-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months.  Surgical placement and removal of implants 1 per tooth space per 60 months.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420007,60597ID0420007-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420007,60597ID0420007-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420007,60597ID0420007-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420007,60597ID0420007-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420007,60597ID0420007-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420007,60597ID0420007-01,"Orthodontia - Child",Yes,,Yes,,,,,"Coverage for orthodontia services are excluded unless medically necessary.","Medically necessary orthodontia requires a predetermination and a treatment plan.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420007,60597ID0420007-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420008,60597ID0420008-01,"Accidental Dental",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420008,60597ID0420008-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420008,60597ID0420008-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420008,60597ID0420008-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420008,60597ID0420008-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420008,60597ID0420008-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420008,60597ID0420008-01,"Orthodontia - Child",Yes,,Yes,,,,,"Coverage for orthodontia services are excluded unless medically necessary.","Medically necessary orthodontia requires a predetermination and a treatment plan.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420008,60597ID0420008-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0420008,60597ID0420008-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months.  Surgical placement and removal of implants 1 per tooth space per 60 months.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430001,60597ID0430001-01,"Routine Dental Services (Adult)",No,,Yes,,,,,"Space maintainers, athletic mouth guards, and sealants are not covered for members age 19 and older.","Periodic exams 2 per year. Comprehensive exams 2 per year. Full mouth, cone beams, or panorex x-rays 1 set per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 3 per year. Fluoride applications 4 per year. Brush biopsies to aid in diagnosis of oral cancer are covered. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430001,60597ID0430001-01,"Accidental Dental",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430001,60597ID0430001-01,"Orthodontia - Child",Yes,,Yes,,,,,"Coverage for orthodontia services are excluded unless medically necessary.","Medically necessary orthodontia requires a predetermination and a treatment plan.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430001,60597ID0430001-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430001,60597ID0430001-01,"Basic Dental Care - Adult",No,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 36 month only if no prophylaxis in the prior 36 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Charge for root canal therapy 1 per tooth per 36 months. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430001,60597ID0430001-01,"Major Dental Care - Adult",No,,Yes,,,,,"Separate charges for denture adjustments and relines performed within 6 months of initial placement.","Crowns and other restorations 1 per tooth per 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months. Initial placement only covered if natural tooth lost or extracted while coverage is in effect or after at least 36 consecutive months. Surgical placement and removal of implants 1 per tooth space per lifetime. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430001,60597ID0430001-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months.  Surgical placement and removal of implants 1 per tooth space per 60 months.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430001,60597ID0430001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430001,60597ID0430001-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430002,60597ID0430002-01,"Basic Dental Care - Adult",No,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 36 month only if no prophylaxis in the prior 36 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Charge for root canal therapy 1 per tooth per 36 months. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430002,60597ID0430002-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430002,60597ID0430002-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430002,60597ID0430002-01,"Accidental Dental",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430002,60597ID0430002-01,"Orthodontia - Child",Yes,,Yes,,,,,"Coverage for orthodontia services are excluded unless medically necessary.","Medically necessary orthodontia requires a predetermination and a treatment plan.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430002,60597ID0430002-01,"Major Dental Care - Adult",No,,Yes,,,,,"Separate charges for denture adjustments and relines performed within 6 months of initial placement.","Crowns and other restorations 1 per tooth per 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months. Initial placement only covered if natural tooth lost or extracted while coverage is in effect or after at least 36 consecutive months. Surgical placement and removal of implants 1 per tooth space per lifetime. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430002,60597ID0430002-01,"Routine Dental Services (Adult)",No,,Yes,,,,,"Space maintainers, athletic mouth guards, and sealants are not covered for members age 19 and older.","Periodic exams 2 per year. Comprehensive exams 2 per year. Full mouth, cone beams, or panorex x-rays 1 set per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 3 per year. Fluoride applications 4 per year. Brush biopsies to aid in diagnosis of oral cancer are covered. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430002,60597ID0430002-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months.  Surgical placement and removal of implants 1 per tooth space per 60 months.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430002,60597ID0430002-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430003,60597ID0430003-01,"Orthodontia - Child",Yes,,Yes,,,,,"Coverage for orthodontia services are excluded unless medically necessary.","Medically necessary orthodontia requires a predetermination and a treatment plan.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430003,60597ID0430003-01,"Accidental Dental",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430003,60597ID0430003-01,"Major Dental Care - Adult",No,,Yes,,,,,"Separate charges for denture adjustments and relines performed within 6 months of initial placement.","Crowns and other restorations 1 per tooth per 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months. Initial placement only covered if natural tooth lost or extracted while coverage is in effect or after at least 36 consecutive months. Surgical placement and removal of implants 1 per tooth space per lifetime. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430003,60597ID0430003-01,"Routine Dental Services (Adult)",No,,Yes,,,,,"Space maintainers, athletic mouth guards, and sealants are not covered for members age 19 and older.","Periodic exams 2 per year. Comprehensive exams 2 per year. Full mouth, cone beams, or panorex x-rays 1 set per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 3 per year. Fluoride applications 4 per year. Brush biopsies to aid in diagnosis of oral cancer are covered. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430003,60597ID0430003-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430003,60597ID0430003-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430003,60597ID0430003-01,"Basic Dental Care - Adult",No,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 36 month only if no prophylaxis in the prior 36 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Charge for root canal therapy 1 per tooth per 36 months. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430003,60597ID0430003-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430003,60597ID0430003-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months.  Surgical placement and removal of implants 1 per tooth space per 60 months.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430004,60597ID0430004-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430004,60597ID0430004-01,"Major Dental Care - Adult",No,,Yes,,,,,"Separate charges for denture adjustments and relines performed within 6 months of initial placement.","Crowns and other restorations 1 per tooth per 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months. Initial placement only covered if natural tooth lost or extracted while coverage is in effect or after at least 36 consecutive months. Surgical placement and removal of implants 1 per tooth space per lifetime. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430004,60597ID0430004-01,"Basic Dental Care - Adult",No,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 36 month only if no prophylaxis in the prior 36 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Charge for root canal therapy 1 per tooth per 36 months. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430004,60597ID0430004-01,"Routine Dental Services (Adult)",No,,Yes,,,,,"Space maintainers, athletic mouth guards, and sealants are not covered for members age 19 and older.","Periodic exams 2 per year. Comprehensive exams 2 per year. Full mouth, cone beams, or panorex x-rays 1 set per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 3 per year. Fluoride applications 4 per year. Brush biopsies to aid in diagnosis of oral cancer are covered. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430004,60597ID0430004-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430004,60597ID0430004-01,"Accidental Dental",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430004,60597ID0430004-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months.  Surgical placement and removal of implants 1 per tooth space per 60 months.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430004,60597ID0430004-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430004,60597ID0430004-01,"Orthodontia - Child",Yes,,Yes,,,,,"Coverage for orthodontia services are excluded unless medically necessary.","Medically necessary orthodontia requires a predetermination and a treatment plan.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430005,60597ID0430005-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430005,60597ID0430005-01,"Major Dental Care - Adult",No,,Yes,,,,,"Separate charges for denture adjustments and relines performed within 6 months of initial placement.","Crowns and other restorations 1 per tooth per 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months. Initial placement only covered if natural tooth lost or extracted while coverage is in effect or after at least 36 consecutive months. Surgical placement and removal of implants 1 per tooth space per lifetime. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430005,60597ID0430005-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430005,60597ID0430005-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months.  Surgical placement and removal of implants 1 per tooth space per 60 months.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430005,60597ID0430005-01,"Orthodontia - Child",Yes,,Yes,,,,,"Coverage for orthodontia services are excluded unless medically necessary.","Medically necessary orthodontia requires a predetermination and a treatment plan.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430005,60597ID0430005-01,"Accidental Dental",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430005,60597ID0430005-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430005,60597ID0430005-01,"Routine Dental Services (Adult)",No,,Yes,,,,,"Space maintainers, athletic mouth guards, and sealants are not covered for members age 19 and older.","Periodic exams 2 per year. Comprehensive exams 2 per year. Full mouth, cone beams, or panorex x-rays 1 set per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 3 per year. Fluoride applications 4 per year. Brush biopsies to aid in diagnosis of oral cancer are covered. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430005,60597ID0430005-01,"Basic Dental Care - Adult",No,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 36 month only if no prophylaxis in the prior 36 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Charge for root canal therapy 1 per tooth per 36 months. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430006,60597ID0430006-01,"Basic Dental Care - Child",Yes,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430006,60597ID0430006-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Year",,,"Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430006,60597ID0430006-01,"Routine Dental Services (Adult)",No,,Yes,,,,,"Space maintainers, athletic mouth guards, and sealants are not covered for members age 19 and older.","Periodic exams 2 per year. Comprehensive exams 2 per year. Full mouth, cone beams, or panorex x-rays 1 set per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 3 per year. Fluoride applications 4 per year. Brush biopsies to aid in diagnosis of oral cancer are covered. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430006,60597ID0430006-01,"Accidental Dental",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430006,60597ID0430006-01,"Basic Dental Care - Adult",No,,Yes,,,,,,"Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 36 month only if no prophylaxis in the prior 36 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Charge for root canal therapy 1 per tooth per 36 months. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430006,60597ID0430006-01,"Major Dental Care - Adult",No,,Yes,,,,,"Separate charges for denture adjustments and relines performed within 6 months of initial placement.","Crowns and other restorations 1 per tooth per 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months. Initial placement only covered if natural tooth lost or extracted while coverage is in effect or after at least 36 consecutive months. Surgical placement and removal of implants 1 per tooth space per lifetime. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information.","Not EHB",,,Yes,Yes
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430006,60597ID0430006-01,"Major Dental Care - Child",Yes,,Yes,,,,,,"Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months.  Surgical placement and removal of implants 1 per tooth space per 60 months.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430006,60597ID0430006-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0430006,60597ID0430006-01,"Orthodontia - Child",Yes,,Yes,,,,,"Coverage for orthodontia services are excluded unless medically necessary.","Medically necessary orthodontia requires a predetermination and a treatment plan.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440001,60597ID0440001-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440003,60597ID0440003-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440004,60597ID0440004-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0440005,60597ID0440005-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450001,60597ID0450001-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450003,60597ID0450003-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450004,60597ID0450004-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Nutritional Counseling",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Gender Affirming Care",No,,No,,,,,,"Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.",,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Prosthetic Devices",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"This health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Home Health Care Services",Yes,,Yes,,,,,"Private duty nursing is not covered.","Covered services include services by a licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Accidental Dental",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Habilitation Services",Yes,,Yes,,,,,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Specialty Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Generic Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Infusion Therapy",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,Acupuncture,No,,Yes,Yes,18,"Visit(s) per Benefit Period",,"Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies. ","Benefits are subject to a maximum combined benefit of 18 visits for acupuncture and chiropractic care.","Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Specialist Visit",Yes,,Yes,,,,,"Missed appointments and get acquainted visits. See policy for more information.",,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Routine Foot Care",No,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Routine Eye Exam (Adult)",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Cosmetic Surgery",No,,Yes,Yes,1,"Procedure(s) per Episode",,"Cosmetic surgery (except in certain situations). See policy for more information.","Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.","Additional EHB Benefit",,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Emergency Room Services",Yes,,Yes,,,,,"The benefit does not cover further treatment provided on referral from the emergency room. ","For emergency medical conditions, out-of-network providers are paid at the in network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,"Charges for inpatient stays that began before you were covered by this plan.","Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,"Immunizations when recommended for or in anticipation of exposure through travel or work.","See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.",,,,No,No
2024,ID,60597,SERFF,1,2/12/2024,60597ID0450005,60597ID0450005-01,"Durable Medical Equipment",Yes,,Yes,,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID1710001,61589ID1710001-01,"Basic Dental Care - Child",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID1710001,61589ID1710001-01,"Major Dental Care - Child",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID1710001,61589ID1710001-01,"Major Dental Care - Adult",No,,Yes,Yes,1250,"Dollars per Benefit Period",,,"Major services are subject to a 12-month waiting period.","Not EHB",,,Yes,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID1710001,61589ID1710001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID1710001,61589ID1710001-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID1710001,61589ID1710001-01,"Orthodontia - Child",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID1710001,61589ID1710001-01,"Routine Dental Services (Adult)",No,,Yes,Yes,1250,"Dollars per Benefit Period",,,"Adult benefits may differ from those displayed here.  Please see plan brochure for adult benefits.","Not EHB",,,Yes,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID1710001,61589ID1710001-01,"Basic Dental Care - Adult",No,,Yes,Yes,1250,"Dollars per Benefit Period",,,"Basic services are subject to a 6-month waiting period.","Not EHB",,,Yes,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID1710001,61589ID1710001-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID1720001,61589ID1720001-01,"Major Dental Care - Child",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID1720001,61589ID1720001-01,"Major Dental Care - Adult",No,,Yes,Yes,1000,"Dollars per Benefit Period",,,"Major services are subject to a 12-month waiting period.","Not EHB",,,Yes,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID1720001,61589ID1720001-01,"Routine Dental Services (Adult)",No,,Yes,Yes,1000,"Dollars per Benefit Period",,,"Adult benefits may differ from those displayed here.  Please see plan brochure for adult benefits.","Not EHB",,,Yes,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID1720001,61589ID1720001-01,"Basic Dental Care - Child",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID1720001,61589ID1720001-01,"Basic Dental Care - Adult",No,,Yes,Yes,1000,"Dollars per Benefit Period",,,"Basic services are subject to a 6-month waiting period.","Not EHB",,,Yes,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID1720001,61589ID1720001-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID1720001,61589ID1720001-01,"Orthodontia - Child",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID1720001,61589ID1720001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID1720001,61589ID1720001-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID1920001,61589ID1920001-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID1920001,61589ID1920001-01,"Routine Dental Services (Adult)",No,,Yes,Yes,1000,"Dollars per Benefit Period",,,"Adult benefits may differ from those displayed here.  Please see plan brochure for adult benefits.","Not EHB",,,Yes,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID1920001,61589ID1920001-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID1920001,61589ID1920001-01,"Basic Dental Care - Adult",No,,Yes,Yes,1000,"Dollars per Benefit Period",,,"Basic services are subject to a 6-month waiting period.","Not EHB",,,Yes,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID1920001,61589ID1920001-01,"Basic Dental Care - Child",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID1920001,61589ID1920001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID1920001,61589ID1920001-01,"Major Dental Care - Child",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID1920001,61589ID1920001-01,"Orthodontia - Child",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID1920001,61589ID1920001-01,"Major Dental Care - Adult",No,,Yes,Yes,1000,"Dollars per Benefit Period",,,"Major services are subject to a 12-month waiting period.","Not EHB",,,Yes,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID1930001,61589ID1930001-01,"Basic Dental Care - Adult",No,,Yes,Yes,1000,"Dollars per Benefit Period",,,"Basic services are subject to a 6-month waiting period.","Not EHB",,,Yes,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID1930001,61589ID1930001-01,"Routine Dental Services (Adult)",No,,Yes,Yes,1000,"Dollars per Benefit Period",,,"Adult benefits may differ from those displayed here.  Please see plan brochure for adult benefits.","Not EHB",,,Yes,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID1930001,61589ID1930001-01,"Accidental Dental",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID1930001,61589ID1930001-01,"Dental Check-Up for Children",Yes,,Yes,Yes,2,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID1930001,61589ID1930001-01,"Major Dental Care - Child",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID1930001,61589ID1930001-01,"Major Dental Care - Adult",No,,Yes,Yes,1000,"Dollars per Benefit Period",,,"Major services are subject to a 12-month waiting period.","Not EHB",,,Yes,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID1930001,61589ID1930001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID1930001,61589ID1930001-01,"Orthodontia - Child",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID1930001,61589ID1930001-01,"Basic Dental Care - Child",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340003,61589ID2340003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Specialist Visit",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $40 copay.  All other $60 copay.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $20 copay.  All other $40 copay.  Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $20 copay.  All other $40 copay.  Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340007,61589ID2340007-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340008,61589ID2340008-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 after deductible for Preferred Generics and $25 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340009,61589ID2340009-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $10 copay.  All other $30 copay.  Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Specialist Visit",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $30 copay.  All other $50 copay.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340010,61589ID2340010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $10 copay.  All other $30 copay.  Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Specialist Visit",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $20 copay.  All other $40 copay.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $0 copay.  All other $20 copay.  Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $0 copay.  All other $20 copay.  Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340013,61589ID2340013-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Specialist Visit",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $50 copay after deductible.  All other $80 copay after deductible.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $20 for Preferred Generics and $30 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $30 copay.  All other $50 copay.  Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $30 copay.  All other $50 copay.  Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340015,61589ID2340015-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Specialist Visit",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $30 copay.  All other $50 copay.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $10 copay.  All other $30 copay.  Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $10 copay.  All other $30 copay.  Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340016,61589ID2340016-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $30 copay.  All other $50 copay.  Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $20 for Preferred Generics and $30 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $30 copay.  All other $50 copay.  Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340018,61589ID2340018-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Specialist Visit",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $40 copay.  All other $60 copay.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $20 copay.  All other $40 copay.  Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $20 copay.  All other $40 copay.  Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340019,61589ID2340019-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $20 for Preferred Generics and $30 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340020,61589ID2340020-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Specialist Visit",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340021,61589ID2340021-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Specialist Visit",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $20 copay.  All other $40 copay.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $0 copay.  All other $20 copay.  Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $0 copay.  All other $20 copay.  Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340022,61589ID2340022-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $40 copay.  All other $60 copay.  Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $40 copay.  All other $60 copay.  Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Specialist Visit",Yes,,Yes,No,,,,,"This benefit has 2 in network tiers. Choice Docs $60 copay.  All other $80 copay.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2340023,61589ID2340023-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350010,61589ID2350010-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350014,61589ID2350014-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350018,61589ID2350018-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350020,61589ID2350020-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350021,61589ID2350021-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350024,61589ID2350024-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350026,61589ID2350026-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350029,61589ID2350029-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350033,61589ID2350033-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $20 for Preferred Generics and $30 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350038,61589ID2350038-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $20 for Preferred Generics and $30 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350039,61589ID2350039-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $20 for Preferred Generics and $30 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350040,61589ID2350040-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $20 for Preferred Generics and $30 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350041,61589ID2350041-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350045,61589ID2350045-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350046,61589ID2350046-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350047,61589ID2350047-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350048,61589ID2350048-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350064,61589ID2350064-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350079,61589ID2350079-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350087,61589ID2350087-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350093,61589ID2350093-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350094,61589ID2350094-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350095,61589ID2350095-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350096,61589ID2350096-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $20 for Preferred Generics and $30 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350097,61589ID2350097-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $20 for Preferred Generics and $30 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350098,61589ID2350098-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $20 for Preferred Generics and $30 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350099,61589ID2350099-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $20 for Preferred Generics and $30 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350100,61589ID2350100-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350101,61589ID2350101-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350102,61589ID2350102-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350103,61589ID2350103-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350104,61589ID2350104-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350105,61589ID2350105-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350106,61589ID2350106-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350107,61589ID2350107-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350108,61589ID2350108-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 after deductible for Preferred Generics and $25 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350109,61589ID2350109-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 after deductible for Preferred Generics and $25 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350110,61589ID2350110-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 after deductible for Preferred Generics and $25 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350111,61589ID2350111-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 after deductible for Preferred Generics and $25 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350112,61589ID2350112-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350114,61589ID2350114-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350116,61589ID2350116-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350119,61589ID2350119-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350121,61589ID2350121-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350122,61589ID2350122-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $20 for Preferred Generics and $30 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350123,61589ID2350123-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $20 for Preferred Generics and $30 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350124,61589ID2350124-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350125,61589ID2350125-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350126,61589ID2350126-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 after deductible for Preferred Generics and $25 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350127,61589ID2350127-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $20 for Preferred Generics and $30 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350128,61589ID2350128-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $20 for Preferred Generics and $30 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350129,61589ID2350129-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $20 for Preferred Generics and $30 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350130,61589ID2350130-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $20 for Preferred Generics and $30 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350131,61589ID2350131-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $20 for Preferred Generics and $30 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350132,61589ID2350132-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350133,61589ID2350133-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350134,61589ID2350134-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350135,61589ID2350135-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350136,61589ID2350136-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350137,61589ID2350137-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350138,61589ID2350138-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350139,61589ID2350139-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $15 for Preferred Generics and $25 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350140,61589ID2350140-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350141,61589ID2350141-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350142,61589ID2350142-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350143,61589ID2350143-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and/or coinsurance. Cost sharing may not apply for pediatric outpatient psychotherapy.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,"This coinsurance level reflects a coinsurance discount after deductible for specifically listed facilities only.  All other facilities are paid at the standard medical coinsurance after deductible.  For specifically listed  facilities see, bcidaho.com/outpatient surgery.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Specialist Visit",Yes,,Yes,No,,,,,"Referral required for out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"Cost sharing may not apply for pediatric physician office visit.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2350144,61589ID2350144-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360001,61589ID2360001-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360003,61589ID2360003-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360006,61589ID2360006-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360008,61589ID2360008-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360025,61589ID2360025-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360027,61589ID2360027-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360030,61589ID2360030-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360032,61589ID2360032-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360033,61589ID2360033-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360035,61589ID2360035-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360038,61589ID2360038-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360040,61589ID2360040-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360049,61589ID2360049-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360051,61589ID2360051-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360054,61589ID2360054-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360056,61589ID2360056-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360057,61589ID2360057-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360059,61589ID2360059-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360062,61589ID2360062-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360064,61589ID2360064-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360073,61589ID2360073-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360075,61589ID2360075-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360078,61589ID2360078-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360080,61589ID2360080-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360081,61589ID2360081-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360090,61589ID2360090-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360091,61589ID2360091-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360092,61589ID2360092-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360113,61589ID2360113-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360115,61589ID2360115-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360116,61589ID2360116-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360117,61589ID2360117-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360118,61589ID2360118-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360120,61589ID2360120-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360121,61589ID2360121-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360122,61589ID2360122-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360123,61589ID2360123-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360125,61589ID2360125-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360127,61589ID2360127-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $0 for Preferred Generics and $10 for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360129,61589ID2360129-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360139,61589ID2360139-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360140,61589ID2360140-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360141,61589ID2360141-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360142,61589ID2360142-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360143,61589ID2360143-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360145,61589ID2360145-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360146,61589ID2360146-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360147,61589ID2360147-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360148,61589ID2360148-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360149,61589ID2360149-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360150,61589ID2360150-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360151,61589ID2360151-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360152,61589ID2360152-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360154,61589ID2360154-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360155,61589ID2360155-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360156,61589ID2360156-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Specialty Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Generic Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360157,61589ID2360157-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 after deductible for Preferred Generics and $10 after deductible for Non-Preferred generics.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360158,61589ID2360158-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Generics Drugs = $20, Non-Preferred Generic Drugs = $30",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360159,61589ID2360159-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360160,61589ID2360160-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360161,61589ID2360161-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-01,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-02,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-03,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-04,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-05,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Hospice Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Preventive Care/Screening/Immunization",Yes,,Yes,No,,,,,"Benefits displayed here are for preventive care and screening.  Specifically listed immunizations are no charge.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"X-rays and Diagnostic Imaging",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,Transplant,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Emergency Room Services",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,Chemotherapy,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Prenatal and Postnatal Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Basic Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Urgent Care Centers or Facilities",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Specialist Visit",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Well Baby Visits and Care",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,Dialysis,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Home Health Care Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,Radiation,Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Prosthetic Devices",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Emergency Transportation/Ambulance",Yes,,Yes,No,,,,,"In network cost sharing applies to both in network and out of network services for Air Ambulance services only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Generic Drugs",Yes,,Yes,No,,,,,"This benefit has 2 copay tiers. You pay $5 less for Preferred Generic Prescriptions.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Dental Check-Up for Children",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,No,,,,,"Breastfeeding support and supplies no charge in network only.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,No,,,,,"You must select a Primary Care Provider (PCP) with this plan. Please check this plan’s provider network for a list of covered providers. You must have a referral for any care you receive from other providers.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Rehabilitative Speech Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For Eligible Dependent Children Only. Limited to one (1) device per ear, per thirty-six (36) month period.  Delivery of device includes forty-five (45) speech therapy visits during the first year.","Additional EHB Benefit",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Habilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Limit is in and out of network combined per member.  Includes Outpatient Physical, Speech and Occupational Therapy Services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Allergy Testing",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Accidental Dental",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,No,,,,,"Outpatient Facility & Other Professional services are subject to applicable deductible and coinsurance.",,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,No,,,,,"The benefit presented here is for inpatient services.  See above for outpatient rehabilitation and habilitation services.","Substantially Equal",,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Inpatient Physician and Surgical Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Diabetes Education",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Non-Preferred Brand Drugs",Yes,,Yes,No,,,,,,,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Reconstructive Surgery",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Major Dental Care - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Orthodontia - Child",Yes,,No,,,,,,"Dental Only Plan sold separately","Dental Only Plan Available",,,,
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Durable Medical Equipment",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Specialty Drugs",Yes,,Yes,No,,,,,"This benefit has 2 tiers.  Preferred Specialty Drugs = 30% coinsurance after deductible, Non-Preferred Specialty Drugs = 50% coinsurance after deductible.",,,,No,Yes
2024,ID,61589,SERFF,1,2/12/2024,61589ID2360162,61589ID2360162-06,"Infusion Therapy",Yes,,Yes,No,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010007,80588ID0010007-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010008,80588ID0010008-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-04,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-05,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010009,80588ID0010009-06,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-04,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-05,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010010,80588ID0010010-06,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-01,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-02,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010011,80588ID0010011-03,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,"Routine nursing and custodial care are not covered.",,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Orthotics or orthopedic shoes are covered when medically necessary.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,"Known as spinal manipulation in plans.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Once per year for members through the end of the month in which they reach age 19.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"The plan pays up to $2,000 per day for out-of-network non-emergency admission.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions.","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications limited to certain providers or settings.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,"1 in-hospital newborn visit and 6 additional visits for the first year of life.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,"7 exams age 1-4 and one per year age 5 and over.  See policy for other visit limits.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Habilitation Services",Yes,,Yes,,,,,,"Inpatient services are in a hospital or other inpatient facility that specializes in such care.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30 days supply per prescription. Prior authorization required for non-Moda-designated specialty pharmacies.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,Transplant,Yes,,Yes,,,,,,"In-network for Centers of Excellence. Up to 14 days per transplant for travel and housing.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Gender Affirming Care",No,,Yes,,,,,,"See policy for information about gender affirming care.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,"For children with a birth defect or acquired hearing loss that may result in cognitive or speech development deficits if without intervention.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Year",,,"Separate limits for outpatient rehabilitation and outpatient habilitation services. These limits do not apply to medically necessary cardiac or pulmonary rehabilitation or services for mental health and substance use disorder.","Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90 days supply per prescription. One copay for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0010012,80588ID0010012-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,Acupuncture,No,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications may be limited to certain providers or settings",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30-day supply per prescription.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"See handbook for limitations",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Gender Affirming Care",No,,Yes,,,,,,,"Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Separate limits for outpatient rehabilitation and habilitation.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,Transplant,Yes,,Yes,,,,,,"In-network level for centers of excellence. Up to 14 days per transplant for travel and housing",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020017,80588ID0020017-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30-day supply per prescription.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Gender Affirming Care",No,,Yes,,,,,,,"Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,Acupuncture,No,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,Transplant,Yes,,Yes,,,,,,"In-network level for centers of excellence. Up to 14 days per transplant for travel and housing",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications may be limited to certain providers or settings",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"See handbook for limitations",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Separate limits for outpatient rehabilitation and habilitation.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020018,80588ID0020018-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,Acupuncture,No,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30-day supply per prescription.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Separate limits for outpatient rehabilitation and habilitation.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications may be limited to certain providers or settings",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"See handbook for limitations",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Gender Affirming Care",No,,Yes,,,,,,,"Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,Transplant,Yes,,Yes,,,,,,"In-network level for centers of excellence. Up to 14 days per transplant for travel and housing",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020019,80588ID0020019-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,Transplant,Yes,,Yes,,,,,,"In-network level for centers of excellence. Up to 14 days per transplant for travel and housing",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,Acupuncture,No,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications may be limited to certain providers or settings",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"See handbook for limitations",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Separate limits for outpatient rehabilitation and habilitation.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Gender Affirming Care",No,,Yes,,,,,,,"Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30-day supply per prescription.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020020,80588ID0020020-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications may be limited to certain providers or settings",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Gender Affirming Care",No,,Yes,,,,,,,"Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"See handbook for limitations",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Separate limits for outpatient rehabilitation and habilitation.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,Transplant,Yes,,Yes,,,,,,"In-network level for centers of excellence. Up to 14 days per transplant for travel and housing",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,Acupuncture,No,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30-day supply per prescription.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020021,80588ID0020021-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,Transplant,Yes,,Yes,,,,,,"In-network level for centers of excellence. Up to 14 days per transplant for travel and housing",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Separate limits for outpatient rehabilitation and habilitation.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,Acupuncture,No,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30-day supply per prescription.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications may be limited to certain providers or settings",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Gender Affirming Care",No,,Yes,,,,,,,"Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020022,80588ID0020022-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"See handbook for limitations",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Gender Affirming Care",No,,Yes,,,,,,,"Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,Acupuncture,No,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Separate limits for outpatient rehabilitation and habilitation.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications may be limited to certain providers or settings",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,Transplant,Yes,,Yes,,,,,,"In-network level for centers of excellence. Up to 14 days per transplant for travel and housing",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30-day supply per prescription.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"See handbook for limitations",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020023,80588ID0020023-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,Transplant,Yes,,Yes,,,,,,"In-network level for centers of excellence. Up to 14 days per transplant for travel and housing",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,Acupuncture,No,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30-day supply per prescription.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"See handbook for limitations",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Separate limits for outpatient rehabilitation and habilitation.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Gender Affirming Care",No,,Yes,,,,,,,"Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications may be limited to certain providers or settings",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020024,80588ID0020024-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Separate limits for outpatient rehabilitation and habilitation.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30-day supply per prescription.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Gender Affirming Care",No,,Yes,,,,,,,"Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"See handbook for limitations",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications may be limited to certain providers or settings",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,Acupuncture,No,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,Transplant,Yes,,Yes,,,,,,"In-network level for centers of excellence. Up to 14 days per transplant for travel and housing",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020025,80588ID0020025-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications may be limited to certain providers or settings",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,Acupuncture,No,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,Transplant,Yes,,Yes,,,,,,"In-network level for centers of excellence. Up to 14 days per transplant for travel and housing",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"See handbook for limitations",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Gender Affirming Care",No,,Yes,,,,,,,"Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30-day supply per prescription.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Separate limits for outpatient rehabilitation and habilitation.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020026,80588ID0020026-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Gender Affirming Care",No,,Yes,,,,,,,"Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,Transplant,Yes,,Yes,,,,,,"In-network level for centers of excellence. Up to 14 days per transplant for travel and housing",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,Acupuncture,No,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications may be limited to certain providers or settings",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30-day supply per prescription.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Separate limits for outpatient rehabilitation and habilitation.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"See handbook for limitations",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020027,80588ID0020027-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Separate limits for outpatient rehabilitation and habilitation.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Gender Affirming Care",No,,Yes,,,,,,,"Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"See handbook for limitations",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"First 3 INN PCP visits at $5 cost share",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30-day supply per prescription.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,Acupuncture,No,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications may be limited to certain providers or settings",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,Transplant,Yes,,Yes,,,,,,"In-network level for centers of excellence. Up to 14 days per transplant for travel and housing",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020028,80588ID0020028-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,Transplant,Yes,,Yes,,,,,,"In-network level for centers of excellence. Up to 14 days per transplant for travel and housing",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"See handbook for limitations",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,Acupuncture,No,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Separate limits for outpatient rehabilitation and habilitation.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications may be limited to certain providers or settings",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30-day supply per prescription.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"First 3 INN PCP visits at $5 cost share",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Gender Affirming Care",No,,Yes,,,,,,,"Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020029,80588ID0020029-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Gender Affirming Care",No,,Yes,,,,,,,"Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,Acupuncture,No,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications may be limited to certain providers or settings",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30-day supply per prescription.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"See handbook for limitations",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,Transplant,Yes,,Yes,,,,,,"In-network level for centers of excellence. Up to 14 days per transplant for travel and housing",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Separate limits for outpatient rehabilitation and habilitation.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020030,80588ID0020030-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Separate limits for outpatient rehabilitation and habilitation.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Gender Affirming Care",No,,Yes,,,,,,,"Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,Transplant,Yes,,Yes,,,,,,"In-network level for centers of excellence. Up to 14 days per transplant for travel and housing",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications may be limited to certain providers or settings",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,Acupuncture,No,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"See handbook for limitations",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30-day supply per prescription.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020031,80588ID0020031-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Covered for some medical conditions. Prior authorization required after first 5 visits.","Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,Acupuncture,No,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Routine Foot Care",No,,Yes,,,,,,"For covered medical conditions","Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Specialty Drugs",Yes,,Yes,,,,,,"Up to 30-day supply per prescription.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,"Separate limits for outpatient rehabilitation and habilitation.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Chiropractic Care",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Infusion Therapy",Yes,,Yes,,,,,,"Some medications may be limited to certain providers or settings",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Gender Affirming Care",No,,Yes,,,,,,,"Other Law/Regulation",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"See handbook for limitations",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,Transplant,Yes,,Yes,,,,,,"In-network level for centers of excellence. Up to 14 days per transplant for travel and housing",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Benefit Period",,,,"Substantially Equal",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Generic Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,"Up to 90-day supply per prescription. One copay per a 30-day supply.",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Hearing Aids",No,,Yes,Yes,1,"Item(s) per 3 Years",,,,"Not EHB",,,No,No
2024,ID,80588,SERFF,1,2/12/2024,80588ID0020032,80588ID0020032-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Specialist Visit",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Specialist Visit",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Specialist Visit",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010001,91278ID0010001-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Specialist Visit",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Specialist Visit",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Specialist Visit",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Specialist Visit",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-04,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Specialist Visit",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-05,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Specialist Visit",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010002,91278ID0010002-06,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Specialist Visit",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Specialist Visit",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Specialist Visit",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Specialist Visit",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Specialist Visit",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Specialist Visit",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0010009,91278ID0010009-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Specialist Visit",Yes,,Yes,,,,,,"Molina does not require Members to get a referral prior to seeing a specialist.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-01,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Specialist Visit",Yes,,Yes,,,,,,"Molina does not require Members to get a referral prior to seeing a specialist.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-02,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Specialist Visit",Yes,,Yes,,,,,,"Molina does not require Members to get a referral prior to seeing a specialist.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020001,91278ID0020001-03,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Specialist Visit",Yes,,Yes,,,,,,"Molina does not require Members to get a referral prior to seeing a specialist.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Specialist Visit",Yes,,Yes,,,,,,"Molina does not require Members to get a referral prior to seeing a specialist.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Specialist Visit",Yes,,Yes,,,,,,"Molina does not require Members to get a referral prior to seeing a specialist.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Specialist Visit",Yes,,Yes,,,,,,"Molina does not require Members to get a referral prior to seeing a specialist.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Specialist Visit",Yes,,Yes,,,,,,"Molina does not require Members to get a referral prior to seeing a specialist.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Routine Eye Exam (Adult)",No,,Yes,Yes,1,"Exam(s) per Year",,,,"Not EHB",,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Reconstructive Surgery",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Infusion Therapy",Yes,,Yes,,,,,,"All Outpatient infusion therapy including Home Intravenous Therapy drugs as listed on the BCI Web site, www.bcidaho.com require prior authorization.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Hearing Aids",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Rehabilitative Speech Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Cosmetic Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,Transplant,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Nutritional Counseling",Yes,,Yes,Yes,3,"Visit(s) per Benefit Period",,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Orthodontia - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Bariatric Surgery",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Eye Glasses for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Major Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Specialist Visit",Yes,,Yes,,,,,,"Molina does not require Members to get a referral prior to seeing a specialist.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Outpatient Rehabilitation Services",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,"Molina asks Members to select a PCP from our Participating Provider network in the provider directory. If a PCP is not selected, one will be assigned by Molina. Members can request to change their PCP at any time at MyMolina.com or by contacting Customer Support.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Prosthetic Devices",Yes,,Yes,,,,,,"Following cataract Surgery or for the treatment of Keratoconus, benefits for a required contact lens or a pair of eyeglasses are limited to the first contact lens or pair of eyeglasses, which must be purchased within ninety (90) days. Prior Authorization required when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Gender Affirming Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Requires prior authorization when the expected charges exceed five hundred dollars ($500).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Routine Foot Care",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Routine Eye Exam for Children",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twelve (12) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,Chemotherapy,Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Outpatient Psychotherapy services after the tenth (10th) visit (does not include medication management services), Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), Residential Treatment Program, Psychological testing/neuropsychological evaluation testing, Electroconvulsive Therapy (ECT).",,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Basic Dental Care - Adult",No,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,Yes,20,"Visit(s) per Benefit Period",,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Hospice Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Habilitation Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,91278,SERFF,1,2/12/2024,91278ID0020002,91278ID0020002-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170001,92170ID0170001-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170002,92170ID0170002-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-04,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-05,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170003,92170ID0170003-06,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-02,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0170004,92170ID0170004-03,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180001,92170ID0180001-01,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180002,92170ID0180002-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180003,92170ID0180003-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180004,92170ID0180004-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Home Health Care Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Basic Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Urgent Care Centers or Facilities",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Emergency Transportation/Ambulance",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Other Practitioner Office Visit (Nurse, Physician Assistant)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Orthodontia - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Diabetes Education",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Habilitation Services",Yes,,Yes,,,,,,"Office visit copay shown; Inpatient services for Habilitation: please refer to Inpatient Hospital Services for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Long-Term/Custodial Nursing Home Care",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Laboratory Outpatient and Professional Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Emergency Room Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Routine Foot Care",No,,Yes,,,,,,,"Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Routine Dental Services (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Durable Medical Equipment",Yes,,Yes,,,,,,"Pre-Authorization required for some Durable Medical Equipment",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Inpatient Hospital Services (e.g., Hospital Stay)",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Private-Duty Nursing",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Rehabilitative Speech Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Allergy Testing",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Major Dental Care - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Cosmetic Surgery",No,,Yes,,,,,,"Limited Medical Benefit","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Prenatal and Postnatal Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Major Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Abortion for Which Public Funding is Prohibited",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,Dialysis,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Mental/Behavioral Health Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Eye Glasses for Children",Yes,,Yes,Yes,1,"Item(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Weight Loss Programs",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,Acupuncture,No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Generic Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"X-rays and Diagnostic Imaging",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,Chemotherapy,Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Reconstructive Surgery",Yes,,Yes,,,,,,"Limited Medical Benefit",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Infusion Therapy",Yes,,Yes,,,,,,"Pre-Authorization required for some medications",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Nutritional Counseling",Yes,,Yes,,,,,,"Dietary Counseling is covered only if provided by a doctor of medicine (M.D.), doctor of osteopathy (D.O.), Registered Dietitian, Physician Assistant (P.A.), or a Nurse Practitioner (N.P.).","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Imaging (CT/PET Scans, MRIs)",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Non-Preferred Brand Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Routine Eye Exam for Children",Yes,,Yes,Yes,1,"Exam(s) per Year",,,"Covered for children 18 and under.","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Dental Check-Up for Children",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Chiropractic Care",Yes,,Yes,Yes,18,"Visit(s) per Year",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Specialty Drugs",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Accidental Dental",Yes,,Yes,,,,,,"Dental services which are rendered by a Physician or Dentist and required as a result of Accidental Injury to the jaw, Sound Natural Tooth, mouth, or face. Such services are covered only for the twenty -four (24) month period immediately following the date of injury providing the Policy remains in effect during the twelve (12) month period.",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Specialist Visit",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,Transplant,Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Substance Abuse Disorder Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Substance Abuse Disorder Outpatient Services",Yes,,Yes,,,,,,"Office visit copay shown; Outpatient services for Mental/Behavioral Health: please refer to Outpatient Facility Fee for cost sharing",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,Radiation,Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Inpatient Physician and Surgical Services",Yes,,Yes,,,,,,"Pre-Authorization Required",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Orthodontia - Adult",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Outpatient Surgery Physician/Surgical Services",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Bariatric Surgery",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Prosthetic Devices",Yes,,Yes,,,,,,"Pre-Authorization required for some Prosthetic Devices",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Routine Eye Exam (Adult)",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Basic Dental Care - Child",Yes,,No,,,,,,,"Dental Only Plan Available",,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Mental/Behavioral Health Inpatient Services",Yes,,Yes,,,,,,"Mental Health and Substance Abuse Services require prior authorization: Partial Hospitalization Program (PHP), Residential Treatment Program, Inpatient",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Skilled Nursing Facility",Yes,,Yes,Yes,30,"Days per Year",,,"Pre-Authorization Required","Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Primary Care Visit to Treat an Injury or Illness",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Infertility Treatment",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Hospice Services",Yes,,Yes,Yes,12,"Months per Lifetime",,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Preventive Care/Screening/Immunization",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Well Baby Visits and Care",Yes,,Yes,,,,,,,,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Hearing Aids",No,,Yes,Yes,2,"Item(s) per 3 Years",,,"Hearing Aids are covered for dependent children age 25 and younger only","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Outpatient Rehabilitation Services",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Delivery and All Inpatient Services for Maternity Care",Yes,,Yes,,,,,,"Physician charges related to delivery have no member cost sharing; cost sharing for facility fees applies",,,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Gender Affirming Care",No,,Yes,,,,,,"Pre-Authorization Required","Not EHB",,,No,No
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Treatment for Temporomandibular Joint Disorders",No,,No,,,,,,,,,,,
2024,ID,92170,SERFF,1,2/12/2024,92170ID0180005,92170ID0180005-01,"Rehabilitative Occupational and Rehabilitative Physical Therapy",Yes,,Yes,,,,,,,"Substantially Equal",,,No,No
